The relationship between moral reasoning and nurses' professional values in undergraduate nursing students: a descriptive-correlational study.

BACKGROUND: Moral reasoning in nursing is crucial in delivering high-quality patient care and fostering increased job satisfaction among nurses. Adhering to professional values is vital to this profession, and nurses must modify their actions to align with these values. OBJECTIVE: This study aimed to examine the correlation between moral reasoning and professional values among undergraduate nursing students. RESEARCH DESIGN: A descriptive correlational design was recruited. PARTICIPANTS AND RESEARCH CONTEXT: The research was conducted at three nursing schools located in Tehran, Iran. The sample was recruited through random stratified sampling, specifically targeting undergraduate nursing students. The data collection tool comprised a three-part questionnaire, including a demographic information form, the Nursing Dilemma Test, and the Nurses Professional Values Scale Revised Questionnaire. The distribution of questionnaires encompassed both face-to-face and electronic methods. The analysis of data was conducted using SPSS 16 software. The data was analyzed using the independent samples t-test, Pearson's correlation coefficient, and linear regression analysis. The P value of 0.05 was considered significant. ETHICAL CONSIDERATIONS: The Ethics Research Center of Shahid Beheshti University of Medical Sciences approved the study. FINDINGS: Data analysis showed that moral reasoning was directly correlated to professional values (r = 0.528, p < 0.001). The mean scores of Principled Thinking (P.T.), Practical Consideration (P.C.), and Familiarity with similar moral dilemmas of the NDT scale were 42.55 (SD = 12.95), 15.72 (SD = 6.85), 16.08 (SD = 6.67), respectively. Also, the total score of professional values of students was 90.63 (SD = 28.80). CONCLUSION: The findings indicated that moral reasoning and interest in nursing predict students' professional identity. Thus, any effort to enhance interest in the profession can contribute to developing students' professional identity. This can involve incentivizing, enhancing the professional reputation at the community and university levels, and valuing student preferences and necessities.

Developing care behaviors and ethical attitude in nursing education.

AIM: This study aims to determine the effect of education based on the Theory of Human Caring on nursing students' caring behaviors and ethical attitudes. BACKGROUND: It is crucial to plan nursing education holistically, addressing cognitive, psychomotor and affective domains for the comprehensive development of caring behaviors and ethical attitudes. DESIGN: This study employed a convergent mixed-methods approach with randomized pretest-posttest comparisons and qualitative analysis. METHODS: This study was conducted with third-year nursing students at a state university in Ankara, Turkey, in 2021. It comprised a total of 95 participants, with 47 students in the case group and 48 students in the video group. Theoretical education based on the Theory of Human Caring was simultaneously provided to both groups. Following this, one group received practical training using a video-supported teaching method, while the other group received it through a case analysis method. The research used the 'Descriptive Characteristics Form', 'Caring Nurse Patient Interaction Scale (CNPIS)', 'Scale for Attitudes of Ethical Principles (SAEP)' and 'Student Opinion Form on Care Behaviors Education' to collect data. Quantitative data were analyzed using t-tests, Mann-Whitney U tests, Wilcoxon paired two-sample tests and Linear Regression Analysis, with a significance level of p<0.05. Qualitative data were evaluated through document analysis. Permissions were obtained before the research. RESULTS: After the education provided, significant differences were found between the pre-test and post-test scores of both groups (p<0.05). It was determined that there was a statistically significant, positive and generally moderate relationship between the caring behaviors and ethical attitudes of the students. Additionally, participating students reported that they were satisfied with the education provided, stating that the teaching methods increased their motivation and positively influenced their perspectives on caring and its ethical dimensions. CONCLUSIONS: The research findings show significant improvements in nursing students' care behaviors and ethical attitudes following education based on the Human Care Theory, with both case analysis and video-supported teaching methods yielding notable results. Integration of care theories into the nursing undergraduate curriculum, alongside the use of holistic teaching methods, is recommended, along with further randomized controlled trials to assess teaching effectiveness.

Keep quiet or act? Challenges in integrating ethical theory into gerontological nursing care during students' first clinical rotation: A discussion paper.

AIM: The aim of the paper is twofold: 1. To present observations based on first-year nursing students' narratives during clinical rotation in gerontological nursing care; and 2. Explore a nursing educator's reflections on these observations in relation to the didactic and ethical challenges that occurred. BACKGROUND: The teaching of ethics is included in nurse education worldwide. Students are in their first clinical placement in residential care of older persons confronted with the moral complexities of gerontological care, where they get little possibility to share emotions and thoughts about ethically challenging nursing situations with a supervising registered nurse. DESIGN: A critical discussion paper. METHOD: The educator's reflections in this discussion paper are based on a narrative assignment in ethics where first-year nursing students reflect on and describe a nursing situation during their clinical rotation in the residential care of older persons. RESULTS: Most students were acting as mere spectators in the described nursing situation where an older person, ethical standards, or evidence-based care was violated. Some students acted as advocates to the older person and intervened in the situation and a few as inspirers showing alternative ways of handling ethically challenging situations. CONCLUSIONS: Educators in nursing programs at the undergraduate level require time for student-centered formative guidance to foster moral courage and practice. During first-year students' clinical rotation, the learning goals in long-term residential care of older persons are focused on evidence-based basic nursing care. In this, students are confronted with ethically challenging situations, where the possibility to learn from a critical reflective practice is rare. When observing situations where an older person is subjected to unethical or unsafe nursing care it is common that the students take the spectators' role, not knowing how to deal with what is observed. Some students are taking an intervening role by trying to alleviate the vulnerability of the older person. A few are showing moral courage by directly intervening when experiencing unethical or unsafe nursing care or conduct. In this the student can inspire fellow students or staff during their clinical rotation in alternative ways of handling ethically challenging situations. As older persons are the largest demographic group that nurses will experience, educators need a sound knowledge of ethics as well as gerontological care to be able to meet and nurture students' ethical reflections during clinical practice and to foster practical wisdom in nursing.

Current trends and obstacles in off-the-job nursing ethics training in Japanese hospitals: a cross-sectional study.

Objectives: This study aims to fill the existing gap by examining the current status of off-the-job nursing ethics training in large hospitals in Japan and its integration with on-the-job training to provide targeted insights for enhancing future ethics training. Method: A cross-sectional study was conducted among the nursing education staff of large Japanese hospitals [N=309] by self-administered questionnaire. The questionnaire was the following main points 1) current trends in nursing ethics training 2) planners' concerns, and 3) the link between training and clinical practice. Descriptive statistics were used, closed-ended questions were analyzed through simple tabulations while open-ended questions underwent textual analysis. Results: The hospitals of 76.6% (309) conducted off-the-job nursing ethics training. Their training consists of a combination of lectures and exercises. The focus was to raise nurses' awareness of ethical problems or improve their analytical ability. The objectives were to be able to participate in discussions from an ethical perspective. The main problems were the lack of connection with on-the-job, and a shortage of training personnel. Conclusions: The key to providing off-the-job and on-the-job is to create a mechanism for circulation. The implications of the results are the necessity of constructing ethics education in medicine to develop medical professionals who can discuss and act from ethical perspectives. Future research is expected to include the creation of a multidisciplinary ethics training program for the hospital.

Professional Integrity and Ethical Considerations in Simulation.

As healthcare providers, ethical decisions are woven into the fabric of our profession from bedside care to the use of simulation as an educational pedagogy. Simulation as a method for healthcare education began in response to ethical dilemmas in clinical practice. Educators require an interactive approach to education that will keep patients, learners, and faculty psychologically safe, decrease errors in clinical practice, and engage participants, all of which are inherent in simulation-based experiences. Professional integrity and morality are infused throughout simulation design: prebriefing, facilitation, debriefing, and evaluation.

Embedding Nursing Ethics Within Teaching Strategies in Nurse Residency Programs.

Exposing new nurses to theoretical teaching strategies that help them to navigate the ethical challenges in clinical practice is essential for retention and long-term job satisfaction. This article explores the rationale for teaching ethics content in nurse residency programs and ways to navigate ethical decision-making in the clinical setting. Examples of evidence-informed teaching strategies that enhance knowledge retention and reduce the gap between ethical theory and practice are included.

Resilience and Ethics in Nursing Education and Practice: Needs and Opportunities.

BACKGROUND: Nursing faculty and clinicians are leaving the profession due to increased workload and burnout. Evidence-based interventions to build skills in resilience and well-being are encouraged; however, strategies to implement them in nursing curricula and nurse residency programs (NRPs) are not well known. PURPOSE: To understand the current state of resilience, well-being, and ethics content in the curriculum in schools of nursing and NRPs in the state of Maryland as part of a statewide initiative for Renewal, Resilience and Retention of Maryland Nurses (R 3 ). METHODS: A descriptive survey was distributed to leaders of all Maryland nursing schools and NRP directors. RESULTS: Respondents (n = 67) reported minimal resilience, well-being, and ethics content. Teaching modalities included lecture, journaling, mindfulness, and the code of ethics. Barriers included lack of faculty knowledge, low priority, time constraints, and limited resources. CONCLUSION: Resilience, well-being, and ethics content is limited in nursing curricula. Developing educator skills and best practices to foster resilience and ethical practice are needed.

Overview of nursing ethics teaching in Brazilian public higher education institutions.

OBJECTIVES: to outline the teaching of ethics in undergraduate Nursing programs in Brazilian public higher education institutions. METHODS: descriptive and exploratory study, carried out through the documentary analysis of pedagogical projects of undergraduate Nursing programs in Brazil. RESULTS: 153 active undergraduate Nursing programs were found, of which 106 provide the pedagogical project. In addition to deontological teaching, the teaching of ethics was identified in a transversal way associated with themes such as Social Context, Hospital and Community Care, Pharmacology, Systematization of Nursing Care, Surgical Nursing, Epidemiology, Palliative Care, Management in Nursing, Diversity, Women's, Children's, Adolescent's, Adult's and Older People's Health, and Mental Health. FINAL CONSIDERATIONS: the challenge in teaching nursing ethics is its integration with each action of caring, teaching and managing.

Ethics and Well-Being: The Health Professions and the COVID-19 Pandemic.

The COVID-19 pandemic has had a profound impact on health professionals, adding to the moral suffering and burnout that existed prepandemic. The physical, psychological, and moral toll of the pandemic has threatened the well-being and integrity of clinicians. The narrative of self-sacrifice and heroism bolstered people early on but was not sustainable over time. For health professions students, the learning environment changed dramatically, limiting opportunities in direct patient care and raising concerns for meeting training requirements. Learners lost social connections and felt isolated while learning remotely, and they witnessed ethical tensions between patient-centered care and parallel obligations to public health. Worries about transmission of the virus and uncertainty about its management contributed to their moral suffering. Educators adjusted curricula to address the changing ethical landscape. Preparing learners for the realities of their future professional identities requires creation of interprofessional moral communities that provide support and help develop the moral agency and integrity of its members using experiential and relational learning methods. Investing in the well-being and resilience of clinicians, implementing the recommendations of the National Academy of Medicine, and engaging learners and faculty as cocreators of ethical practice have the potential to transform the learning environment. Faculty need to be trained as effective mentors to create safe spaces for exploring challenges and address moral adversity. Ethics education will need to expand to issues related to health systems science, social determinants of health, and public health, and the cultivation of moral sensitivity, character development, professional identity formation, and moral resilience.

Essential components of midwifery ethics education: results of a Delphi study.

OBJECTIVE: Ethical dilemmas are an inevitable part of a midwife's experience in clinical care. Midwifery educational programs have an obligation to provide students the opportunities to acquire the skills and knowledge to recognize and negotiate ethical dilemmas. Implementation of strategies for imparting ethical competencies and clinical ethics decision-making skills in formal midwifery curricula have been challenging and inconsistent. The purpose of this study was to gather information and opinions from midwifery educators and clinical preceptors about the essential components of ethics education for midwifery students in the United States (U.S.), aiming for consensus on key content, competencies, learning outcomes, and teaching strategies. DESIGN: This is an online Delphi study conducted in three rounds. Round 1 consisted of open-ended questions to explore and identify key content, competencies, learning outcomes, and teaching strategies for midwifery ethics education. In Rounds 2 and 3, experts rated statements on a 1 to 7 Likert scale, with positive consensus defined as 70% or more of the experts scoring ≥6. PARTICIPANTS: The panel included midwifery educators (midwifery program directors, faculty, and clinical preceptors) from the United States. FINDINGS: Of the 12 statements on key content of ethics education, midwives emphasized that content promoting an understanding of shared decision-making is essential for inclusion. Of the statements regarding competencies, learning outcomes, and teaching strategies, 20 of 21 statements met consensus, including those related to shared decision-making and ethical decision-making, as well as attributes such as compassion and courage. Midwives did not agree that an essential teaching strategy includes a validated assessment tool for evaluating students on any component of ethics learning (knowledge, skills, behaviour). KEY CONCLUSIONS: This Delphi study reveals what midwifery educators consider essential components of ethics education for midwifery students, with a particular focus on the professional attributes of shared decision-making. IMPLICATIONS FOR PRACTICE: Initial insights about optimal ways to incorporate the essential ethics education components into midwifery program curricula are provided, and more research is needed.

Factors Affecting Nurses' Impact on Social Justice in the Health System.

BACKGROUND: Social inequities in health systems are threats to global health. Considering the important role of nurses in establishing social justice, identification of factors affecting nurses' participation in this area can contribute to the development of social justice. OBJECTIVE: This study aimed to identify factors affecting nurses' participation in establishing social justice in the health system. RESEARCH DESIGN AND METHODS: The study was conducted using conventional qualitative content analysis approach. Purposive sampling was used to select 14 participants in 2019. The data were collected through semi-structured interviews and analyzed concurrently with data gathering. PARTICIPANTS AND RESEARCH CONTEXT: In total, six faculty members, five nursing managers, and three clinical nurses from three different universities were interviewed. ETHICAL CONSIDERATIONS: The research was approved by the Ethics Committee of Urmia University of Medical Sciences in Iran. FINDINGS: Four main themes were found, including inadequate professional authority, insufficient attention to social justice in the area of education, clinical concerns as barriers to professional presence in society, and reflection of personality traits in the profession. These are the main factors affecting nurses' participation in establishing social justice in the health system. DISCUSSION: Authorities need to take effective steps to establish social justice through reforming the health system's policy-making and power-acquisition domains, promoting nurses' involvement in social factors in health issues, and adding professional values as a part of nursing curriculum. The clinical practice environment can also be helpful through providing quality, safe, and cost-effective services. In addition, fair and efficient recruitment process for new nurses can contribute to the establishment of social justice in the health system. CONCLUSION: Macro-level managerial factors such as policy, education, and clinical environment, along with personal factors, play a significant role in the participation of nursing profession in establishing social justice.

Findings from a mixed-methods pragmatic cluster trial evaluating the impact of ethics education interventions on residential care-givers.

There has been little previous research regarding the effectiveness of ethics education interventions for residential care-givers. The Researching Interventions to Promote Ethics in social care project responded to the question: Which is the most effective ethics education intervention for care-givers in residential social care? A pragmatic cluster trial explored the impact of three ethics education interventions for: (a) interactive face-to-face ethics teaching; (b) reflective ethics discussion groups; and (c) an immersive simulation experience. There was also a control arm (d). 144 trial participants were recruited from 39 residential care homes for older people in southern England. Change scores compared across intervention arms showed a significant reduction in work-related moral stress in the teaching arm compared with control group (p = .03); there were no significant differences between control and intervention arms in change scores for moral sensitivity, interpersonal reactivity (empathy) or ethical leadership. Qualitative data themes were as follows: ethical care; care challenges; and ethical care inhibitors. Overall findings stimulate reflection on the value of three different ethics education interventions and the most appropriate means to evaluate their impact. Findings suggest the complexity and diverse nature of ethical competence in care. We suggest a way forward for research evaluating ethics education.

Buenas prácticas éticas de los estudiantes de Enfermería ante el sida y la discapacidad / Good ethical practices of Nursing students when faced with aids and disability

INTRODUCCIÓN: Durante el curso 2017/2018 se realizó una intervención educativa sobre buenas prácticas éticas en el abordaje del sida y de la discapacidad. Los objetivos fueron: analizar, divulgar y concienciar a los estudiantes sobre los problemas éticos de estos colectivos y sobre las buenas prácticas. MÉTODOS: Participaron 185 estudiantes matriculados en la asignatura de Ética y Gestión de Enfermería. Los objetivos se abordaron mediante el trabajo autónomo de búsquedas de información y en 2seminarios presenciales, donde elaboraron pósteres, folletos y vídeos. Al finalizar la experiencia rellenaron un cuestionario de opinión. RESULTADOS: Se agruparon en 39 equipos de 4-5 estudiantes y entregaron 78 trabajos: 52 pósteres, 20 folletos y 6 vídeos. Los trabajos fueron expuestos, durante una semana, coincidiendo con el Día Mundial de la Lucha contra el Sida y con el Día Internacional de las Personas con Discapacidad. CONCLUSIONES: Esta experiencia ha servido para que los estudiantes tomen conciencia de los problemas de estos colectivos vulnerables, además de conseguir la divulgación de buenas prácticas éticas

INTRODUCTION: During the academic year 2017/2018, an educational intervention on good ethical practices was carried out about AIDS and Disability. The objectives were, to analyse, divulge and sensitise students about the ethical problems of these patient groups and about good practices. METHODS: The study included a total of 185 students enrolled in the subject of Ethics and Management of Nursing. The objectives were addressed using independent information searches and attending 2seminars, where they produced posters, brochures and videos. At the end of the experience they produced an opinion questionnaire. RESULTS: They were grouped into 39 teams of 4-5 students, and delivered 78 works, 52 of which were posters, 20 brochures, and 6 videos. The works were presented for a week, coinciding with the World AIDS Day and with the International Day of Persons with Disabilities. CONCLUSIONS: This experience has served to make students aware of the problems of these vulnerable groups, and also for the divulgation of good ethical practice

Teaching Ethics in Classroom Settings: Nursing Faculty Perceptions in Baccalaureate Programs.

BACKGROUND: The complexity of the current health care system has resulted in increasing demands on nurses to act as patient advocates and moral agents. Understanding faculty's experiences teaching ethics is instrumental to deliver ethically competent care. The purpose of this study was to explore the experiences of nursing faculty teaching ethics content in the classroom setting to prelicensure baccalaureate nursing students. METHOD: This qualitative, descriptive phenomenological design asked 11 nursing faculty with recent experience teaching ethics within prelicensure baccalaureate nursing programs to complete qualitative interviews. RESULTS: Participants expressed the importance of teaching ethics in undergraduate nursing curricula but experienced significant challenges. Three main themes were identified in the data analysis: Lacking Prior Preparation, Difficult Content, and No Place Holder for Ethics Content. CONCLUSION: Intentional curriculum design incorporating ethics content is necessary for the preparation of prelicensure nursing students, along with formal and informal opportunities for faculty to explore ethics including philosophical underpinnings. [J Nurs Educ. 2020;59(9):506-509.].

The Effectiveness of Teaching Nursing Ethics via Scenarios and Group Discussion in Nurses' Adherence to Ethical Codes and Patients' Satisfaction with Nurses' Performance.

BACKGROUND: There are shortcomings in nurses' adherence to ethical principles in practice. The present study aims to investigate the effectiveness of teaching nursing ethics via scenario-based learning and group discussion in nurses' adherence to codes of ethics and patients' satisfaction with nurses' performance. METHODS: Using a quasiexperimental design, the present study employed questionnaires which measure nurses' compliance with nursing codes of ethics and patients' satisfaction with nursing care before, immediately after, and one month after intervention. The collected data were analyzed using the independent t-test, ANOVA, and chi-square test in SPSS v.22. The level of significance was set at p < 0.05. The nurses (n = 80) and patients (n = 160) from various units of two university hospitals in the south-west of Iran participated in the present study. RESULTS: The pretest mean scores of the intervention and control groups in patient rights and patients' satisfaction with nursing care were not significantly different (p=0.07, p=0.21). Yet, there were statistically significant differences between the groups' mean scores as calculated immediately after (p < 0.001, p < 0.001) and one month after intervention (p < 0.001, p < 0.001). CONCLUSION: Employment of new approaches to teach nursing ethical principles improves compliance with nursing ethical codes and patients' satisfaction with nurses' performance.

Analysis of Undergraduate Nursing Students' Sensitivity to Microethical Dilemmas During Simulation.

BACKGROUND: Simulation can extend ethics education in undergraduate nursing programs beyond the cognitive domain. However, the degree to which nursing students recognize and respond to microethical dilemmas in simulation is unknown. METHOD: Using a mixed-methods convergent parallel design, 68 third- and fourth-year undergraduate nursing students completed a sensitivity questionnaire. Twelve students also participated in an interview. Data were compared to create meaning. RESULTS: Many students reported having a high level of ethical sensitivity toward microethical dilemmas during simulation. However, some students expressed uncertainty in their ability to identify microethical dilemmas during nurse-patient interactions. Students also reported limited confidence in being able to transfer their ethical knowledge to the practice setting. CONCLUSION: Nurse educators must be moral agents during simulated learning experiences by helping students learn what microethical dilemmas are and strategies to manage them. [J Nurs Educ. 2020;59(2):88-92.].

Professional values and ethical ideology: Perceptions of nursing students.

BACKGROUND: Moral philosophical positions and professional values have been shown to influence nurses' practice behaviours. Understanding nursing students' professional values and ethical ideologies, therefore, is important as they may help inform evidence-informed curriculum decisions and education strategies to develop students' professional reflective competencies. However, there is a dearth in current empirical data on Canadian nursing students' perceptions of professional values and ethical positions. OBJECTIVES: This study's purpose was to examine undergraduate nursing student's perceptions of professional values and ethical ideology and explore relationships in data and selected participant demographic variables. RESEARCH DESIGN, PARTICIPANTS AND CONTEXT: A descriptive cross-sectional research design was conducted with a convenience sample of undergraduate nursing students recruited from a university in Canada. An online encrypted survey consisting of two validated instruments was administered to participants who met study eligibility criteria. Descriptive and inferential statistics were employed to analyse the data and classify nursing students' ethical ideologies into four categories based on mean scores for idealism and relativism. ETHICAL CONSIDERATIONS: This study received ethical approval from the institutional Behavioural Research Ethics Board and was executed in-line with ethical principles for research involving humans. FINDINGS: Nursing students scored high on professional values and ethical idealism and differed significantly on a measure of ethical relativism in terms of age and year of study. Professional values were significantly associated with ethical idealism. Based on mean scores for idealism and relativism, most nursing students in the study were classified as situationists. DISCUSSION AND CONCLUSION: Findings suggest that faculty pay attention to influences of moral philosophical positions in facilitating nursing students' professional values development. Implications for future research and curriculum are highlighted to strengthen nursing students' professional values.

Relationships between organizational and individual support, nurses' ethical competence, ethical safety, and work satisfaction.

BACKGROUND: Organizations and nurse leaders do not always effectively support nurses' ethical competence. More information is needed about nurses' perceptions of this support and relevant factors to improve it. PURPOSE: The aim of the study was to examine relationships between nurses' perceived organizational and individual support, ethical competence, ethical safety, and work satisfaction. METHODOLOGY: A cross-sectional questionnaire survey was conducted. Questionnaires were distributed to nurses (n = 298) working in specialized, primary, or private health care in Finland. Descriptive statistics, multifactor analysis of variance, and linear regression analysis were used to test the relationships. RESULTS: The nurses reported low organizational and individual support for their ethical competence, whereas perceptions of their ethical competence, ethical safety, and work satisfaction were moderate. There were statistically significant positive correlations between both perceived individual and organizational support, and ethical competence, nurses' work satisfaction, and nurses' ethical safety. CONCLUSIONS: Organizational and individual support for nurses' ethical competence should be strengthened, at least in Finland, by providing more ethics education and addressing ethical problems in multiprofessional discussions. Findings confirm that organizational level support for ethical competence improves nurses' work satisfaction. They also show that individual level support improves nurses' sense of ethical safety, and both organizational and individual support strengthen nurses' ethical competence. PRACTICE IMPLICATIONS: These findings should assist nurse leaders to implement effective support practices to strengthen nurses' ethical competence, ethical safety, and work satisfaction.

Nursing Students' Professional Value Development: Can We Do Better?

AIM: The purpose of this study was to identify whether differences exist in nursing professional values based on program type and/or geographic location. BACKGROUND: Deliberate inclusion of values formation is critical to nursing education and high-quality nursing care. There is limited research comparing professional values development among students in all types of prelicensure RN programs and no research comparing students' professional values between geographic regions. METHOD: A secondary analysis was completed of original data collected in three descriptive studies using the Nursing Professional Value Scale-Revised®. RESULTS: Findings indicate prelicensure nursing students are educated with the values integrated within the American Nurses Association Code of Ethics. Significant differences (p < .05) were found when comparing geographic locations, program types, and Nursing Professional Value Scale-Revised factor scores. CONCLUSION: Additional research is needed to identify best practices for overall values formation in all program types.